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Hello, I Ve Had A Problem For The Last 6-8

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Posted on Sun, 23 Jun 2019
Question: Hello,

I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias yes, but no actual complete numbness anywhere. Also some parasthesias at the time in the genital region. Sensation is preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and three back specialists confirmed that in their opinion this could not be caused by the back.

I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right. The muscles between my fingers are somewhat atrophied, left worse than right. I do NOT have the split hand sign, as both sides of my palm muscles seem to be affected. Heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one spine doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for 6 months, and then getting worse, etc.

Reflexes in arms are diminished, reflexes in knees are absent. Babinski sign and Hoffman sign are both normal. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring and attributable to the esophageal spasms. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two 20-30 minute time periods during the day with many shorter walks to kitchen or bathroom. Total time on my feet is about 1 – 1 ½ hours per day. Total out of bed time is about 3-4 hours per day. I drive short distances and use the scooter at the grocery store. Morning activity makes me profoundly fatigued and takes many hours to recover from. It seems that after 6 years I should have recovered more, and simple “deconditioning” does not seem to fully explain what is going on. Workups for Lupus and Rhuematoid arthitis were negative.

Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this and they have always been this low, regardless of what I ear. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal now but may have been slightly low before).

QUESTION: what is the differential diagnosis for this pattern of weakness, fasciculations, parasthesias, and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
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Follow up: Dr. Dr.Dorina Gurabardhi (0 minute later)
Hello,

I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias yes, but no actual complete numbness anywhere. Also some parasthesias at the time in the genital region. Sensation is preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and three back specialists confirmed that in their opinion this could not be caused by the back.

I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right. The muscles between my fingers are somewhat atrophied, left worse than right. I do NOT have the split hand sign, as both sides of my palm muscles seem to be affected. Heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one spine doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for 6 months, and then getting worse, etc.

Reflexes in arms are diminished, reflexes in knees are absent. Babinski sign and Hoffman sign are both normal. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring and attributable to the esophageal spasms. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two 20-30 minute time periods during the day with many shorter walks to kitchen or bathroom. Total time on my feet is about 1 – 1 ½ hours per day. Total out of bed time is about 3-4 hours per day. I drive short distances and use the scooter at the grocery store. Morning activity makes me profoundly fatigued and takes many hours to recover from. It seems that after 6 years I should have recovered more, and simple “deconditioning” does not seem to fully explain what is going on. Workups for Lupus and Rhuematoid arthitis were negative.

Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this and they have always been this low, regardless of what I ear. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal now but may have been slightly low before).

QUESTION: what is the differential diagnosis for this pattern of weakness, fasciculations, parasthesias, and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
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Follow up: Dr. Dr.Dorina Gurabardhi (44 minutes later)
Few more pieces of info I forgot, not sure if any is relevant: history of alcoholism, sober since 2013. Testing of autonomic response shows underfunctioning parasympathic system and overactive sympathetic, they say this indicated vagus nerve problems. Blood pressure can go abnormally high in response to cold, gastrointestinal upset, urinary upset, and emotion. Gerd can send BP up by as much as 40 points. Depression and PTSD.
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Follow up: Dr. Dr.Dorina Gurabardhi (0 minute later)
Few more pieces of info I forgot, not sure if any is relevant: history of alcoholism, sober since 2013. Testing of autonomic response shows underfunctioning parasympathic system and overactive sympathetic, they say this indicated vagus nerve problems. Blood pressure can go abnormally high in response to cold, gastrointestinal upset, urinary upset, and emotion. Gerd can send BP up by as much as 40 points. Depression and PTSD.
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Follow up: Dr. Dr.Dorina Gurabardhi (6 minutes later)
Lately tremors in hands after overuse. Tremor happens only in response to overuse and only during moving. Is not there when rested and is never there when resTING.
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Follow up: Dr. Dr.Dorina Gurabardhi (0 minute later)
Lately tremors in hands after overuse. Tremor happens only in response to overuse and only during moving. Is not there when rested and is never there when resTING.
doctor
Answered by Dr. Dr.Dorina Gurabardhi (1 hour later)
Brief Answer:
Probably a benign fasciculation syndrome.

Detailed Answer:
Hello and Welcome to ‘Ask A Doctor’ service. I have reviewed your query and here is my advice.

I read carefully your query.

There are some medical conditions that can cause your symptoms.

One of the medical conditions that can cause your symptoms is benign fasciculation syndrome.

It is characterized by twitching, tingling, or numbness in one or more of the muscles.

It is a condition that can develop after the depression.

The treatment consists in mainly in a healthy lifestyle.

I suggest eating a healthful diet rich in whole foods and nutrients, practicing daily exercise, and reducing the stress on the daily basis.

I suggest taking a daily supplement of vitamin B12, acid folic and magnesium.

Hope I have answered your query. Let me know if I can assist you further.

Above answer was peer-reviewed by : Dr. Prasad
doctor
doctor
Answered by Dr. Dr.Dorina Gurabardhi (0 minute later)
Brief Answer:
Probably a benign fasciculation syndrome.

Detailed Answer:
Hello and Welcome to ‘Ask A Doctor’ service. I have reviewed your query and here is my advice.

I read carefully your query.

There are some medical conditions that can cause your symptoms.

One of the medical conditions that can cause your symptoms is benign fasciculation syndrome.

It is characterized by twitching, tingling, or numbness in one or more of the muscles.

It is a condition that can develop after the depression.

The treatment consists in mainly in a healthy lifestyle.

I suggest eating a healthful diet rich in whole foods and nutrients, practicing daily exercise, and reducing the stress on the daily basis.

I suggest taking a daily supplement of vitamin B12, acid folic and magnesium.

Hope I have answered your query. Let me know if I can assist you further.

Above answer was peer-reviewed by : Dr. Prasad
doctor
default
Follow up: Dr. Dr.Dorina Gurabardhi (42 minutes later)
Question:

Can benign fasciculation syndrome cause any of the following: 1) EMG changes, decreased motor units, multilevel radiculopathy, etc. 2) visible atrophy 3) clinical weakness 4) profound fatigue and weakness after exercise 5) tremors in hands when fatigued.

You mentioned "some" medical conditions (i.e. more than one) that can explain this constellation of symptoms/signs.

My goal here is to get the full list of potentials, i.e the full list of differential diagnoses, in an effort to follow up and eliminate any that may be of a more serious nature.

Can you please provide a full list of items to be included in the differential?

default
Follow up: Dr. Dr.Dorina Gurabardhi (0 minute later)
Question:

Can benign fasciculation syndrome cause any of the following: 1) EMG changes, decreased motor units, multilevel radiculopathy, etc. 2) visible atrophy 3) clinical weakness 4) profound fatigue and weakness after exercise 5) tremors in hands when fatigued.

You mentioned "some" medical conditions (i.e. more than one) that can explain this constellation of symptoms/signs.

My goal here is to get the full list of potentials, i.e the full list of differential diagnoses, in an effort to follow up and eliminate any that may be of a more serious nature.

Can you please provide a full list of items to be included in the differential?

doctor
Answered by Dr. Dr.Dorina Gurabardhi (22 hours later)
Brief Answer:
explained below

Detailed Answer:
Hi again dear,

The differential diagnosis should be done with amyotrophic lateral sclerosis .

It’s a disease that affects your motor neurons.

You should follow up with a neurologist for further evaluation.

Another possible cause can be peripheral neuropathy caused by prediabetes.

I also recommend doing a glycosylated hemoglobin for further evaluation.

Hope it helps dear,

Dr.Dorina Gurabardhi
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
doctor
Answered by Dr. Dr.Dorina Gurabardhi (0 minute later)
Brief Answer:
explained below

Detailed Answer:
Hi again dear,

The differential diagnosis should be done with amyotrophic lateral sclerosis .

It’s a disease that affects your motor neurons.

You should follow up with a neurologist for further evaluation.

Another possible cause can be peripheral neuropathy caused by prediabetes.

I also recommend doing a glycosylated hemoglobin for further evaluation.

Hope it helps dear,

Dr.Dorina Gurabardhi
Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.

Above answer was peer-reviewed by : Dr. Raju A.T
doctor
Answered by
Dr.
Dr. Dr.Dorina Gurabardhi

General & Family Physician

Practicing since :2013

Answered : 13558 Questions

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Hello, I Ve Had A Problem For The Last 6-8

Hello, I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias yes, but no actual complete numbness anywhere. Also some parasthesias at the time in the genital region. Sensation is preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and three back specialists confirmed that in their opinion this could not be caused by the back. I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right. The muscles between my fingers are somewhat atrophied, left worse than right. I do NOT have the split hand sign, as both sides of my palm muscles seem to be affected. Heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one spine doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for 6 months, and then getting worse, etc. Reflexes in arms are diminished, reflexes in knees are absent. Babinski sign and Hoffman sign are both normal. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring and attributable to the esophageal spasms. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two 20-30 minute time periods during the day with many shorter walks to kitchen or bathroom. Total time on my feet is about 1 – 1 ½ hours per day. Total out of bed time is about 3-4 hours per day. I drive short distances and use the scooter at the grocery store. Morning activity makes me profoundly fatigued and takes many hours to recover from. It seems that after 6 years I should have recovered more, and simple “deconditioning” does not seem to fully explain what is going on. Workups for Lupus and Rhuematoid arthitis were negative. Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this and they have always been this low, regardless of what I ear. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal now but may have been slightly low before). QUESTION: what is the differential diagnosis for this pattern of weakness, fasciculations, parasthesias, and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.